Contraceptive Pill Questionnaire – Virtual Reviews Patient DetailsName First Last Date of Birth DD slash MM slash YYYY Mobile NumberNHS Number if known OptionalNominated Pharmacy OptionalEmail Address Date completed form DD slash MM slash YYYY Contraceptive ChoicesNHS contraceptive choices1. What is the name of the current pill you are taking?2. When do you next require a prescription (please state how many pills you have left)3. Are you happy with the current pill or do you wish to discuss an alternate contraception?4. Have you previously discussed alternative choices of contraception and possible risks with a health professional?5. How long have you been taking your current pill for?Missed PillsMissed combined pillsMissed Progesterone pills6. Do you know what to do if you miss a pill?Health Check7. Do you ever suffer with migraines or headaches? (please state when they started and how often / severe they are)8. If you suffer with migraines or headaches, are these accompanied with visual (eye) disturbances?9. Have you ever been told you have had a blood clot such as a Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE)10. Do you have a 7-day break on your current pill regime?11. Have you noticed any bleeding between your periods?12. Have you noticed any bleeding after intercourse?Sexual HealthLeeds Sexual Health Clinic13. Have you noticed any new and unusual vaginal discharge14. Have you had any new partners recently?Cancer ScreeningNHS Cancer screening15. Do you examine your breast regularly to detect for any lumps?NHS Cervical Screening16. Are you up to date with your smear tests? (Every 3 years between the age of 25-49yrs then every 5 years)NHS Health Check17. Do you have any family history of breast cancer, heart disease or strokes? (please state who and what ages they were if known)Blood PressureNHS Blood Pressure18. If you have checked your blood pressure, please tell us what it is and the date or month this was checked? (if you have not had your blood pressure checked within the last 12 months, please arrange for this to be checked before your next pill prescription is due) OptionalSmokingNHS smoking cessation19. Are you a Smoker?20. Are you an Ex-smoker?21. Never smoked22. Are you an occasional smoker?23. How many do you smoke each day24. If you are a smoker, would you like help to stop smoking?AlcoholForward Leeds Alcohol Service25. How many units of alcohol would you normally drink each week on average?26. If you drink more than 14 units per week, would you like to discuss your drinking habits further and seek advice and support?Health and WellbeingWe have Health and Wellbeing Coaches who can support patients with weight management and health lifestyle planning. Please let us know if you would like to be booked with them.27. What is your current weight?28. What is your height?29. Do you know what your BMI is?30. If your BMI is over 25, would you like support and advice about weight management?31. How much exercise would you normally do on average each week? (please state the type of exercise)ConcernsIf you need to discuss any concerns before your review, please contact the surgery or go online to book an appointment or use our E consultation Service. 32. Is there anything you would like to discuss with the GP, Pharmacists or Nurse regarding your contraception?33. Please confirm that the information provided has been provided by the patient named on the form?What happens after I have completed the questionnaire?
